ACOG COMMITTEE OPINION

Transcription

1 ACOG COMMITTEE OPINION Number 739 June 2018 Committee on Patient Safety and Quality Improvement This Committee Opinion was developed by the Amerian College of Obstetriians and Gyneologists Committee on Patient Safety and Quality Improvement in ollaboration with Ilana Addis, MD, MPH. The Late-Career Obstetriian Gyneologist ABSTRACT: The Amerian Medial Assoiation reported in 2015 that physiians 65 years and older urrently represent 23% of the physiians in the United States. Unlike other professions suh as ommerial airline pilots, who by law must have regular health sreenings starting at 40 years and must retire at 65 years, few health are institutions or systems have any poliies regarding the late-areer physiian. Although there is an inrease in aumulated wisdom and verbal knowledge with age, there is also an overall deline in reall memory, ognitive proessing effiieny, and exeutive reasoning. The goal of physiians and health are institutions is to provide safe and ompetent are to their patients. Therefore, when onsidering the performane of a physiian, the quality of are provided and safety of the patient are of the utmost importane. It is important to establish systems-based ompeteny assessments to monitor and address physiians health and the effet age has on performane and outomes. Retention strategies an support areas of ognitive or tehnial deline while apitalizing on the aging dotor s strengths, and workplae adaptations should be adopted to help obstetriian gyneologists transition and age well in their pratie and throughout their areers. Reommendations The Amerian College of Obstetriians and Gyneologists makes the following reommendations regarding the late-areer obstetriian gyneologist: It is important to establish systems-based ompeteny assessments to monitor and address physiians health and the effet age has on performane and outomes. Workplae adaptations should be adopted to help obstetriian gyneologists transition and age well in their pratie and throughout their areers. To avoid the potential for legal hallenges, hospitals should address the provisions of the Age Disrimination in Employment At, making sure that assessments are equitably applied to all physiians, regardless of age. Introdution In 2015, the Amerian Medial Assoiation reported that physiians 65 years and older urrently represented 23% of the physiians in the United States (1). The AMA also reported that within this group, 39.3% were atively engaged in patient are (1). Unlike other professions suh as ommerial airline pilots, who by law must have regular health sreenings starting at 40 years and must retire at 65 years, few health are institutions or systems have any poliies regarding the late-areer physiian. Normal aging is a series of time-dependent anatomial and physiologial hanges that are a ombination of primary (intrinsi, programmed ell death) and seondary (extrinsi, wear and tear) fators. These may have a generalized effet on multiple funtions as well as speifi sensory hanges, inluding vision, visual proessing speed, and hearing (2). Additionally, although there is an inrease in aumulated wisdom and verbal knowledge with age, there is also an overall deline in reall memory, ognitive proessing effiieny, and exeutive reasoning (2, 3). The memory of healthy older adults is preserved for well-learned material, but the ability to proess novel information delines, mainly in the area of exeutive funtion. This natural, progressive proess ultimately an redue physiologi reserve, derease speed of information proessing, lead to onfusion or memory loss, and alter e200 VOL. 131, NO. 6, JUNE 2018 OBSTETRICS & GYNECOLOGY

2 psyhomotor performane (3, 4). Dereased ognitive effiieny is seen, in partiular, beyond 75 years of age (4, 5), with resulting onfusion and memory loss being self-reported to interfere with daily life and work (3). Among physiians, the physiologi hanges an present as a derease in effiieny and an affet response time and performane, potentially leading to job diffiulties. These hanges may result in adverse events beause of issues with tehnial skills, ognitive proessing and reasoning, planning, or attention (6). In a physiian with ognitive impairment, one might see more presription errors, irrational business deisions, and loss of skills, and there may be dissatisfied patients, patient injuries, and even lawsuits. In fat, a systemati review showed that in a majority of studies, measures of quality of are dereased with inreasing physiian s length inpratie(7). Understanding the aging proess and its effet is espeially important when addressing its effet within the physiian ommunity. It is essential to onsider all fators in ontext and balane the important benefits of wisdom, knowledge, and experiene that ome with age. Data show that most surgeons reah performane peak at years (8). Aging physiians may have dereased analytial ability and diffiulty inorporating new knowledge, but they also may have better nonanalytial, experiene-based deision-making skills (9). Individual physiians suffering from ognitive impairment may be more likely to minimize their health problems, not take time off, poorly understand and distrust oupational health servies, and self-diagnose and selfpresribe (6). Other physiians, family, olleagues, and institutions may onsiously or unonsiously protet the physiian at the expense of patient are. It is important to establish systems-based ompeteny assessments to monitor and address physiians health and the effet age has on performane and outomes. On an organizational level, there are opportunities, through aspets of the redentialing proess as required by The Joint Commission, that an be applied to addressing pratie onerns in the late-areer obstetriian gyneologist. The Joint Commission requires ongoing and foused professional pratie evaluation of hospital medial staffs. The ongoing professional pratie evaluation proess is intended to allow a hospital to identify professional pratie trends that affet quality of are and patient safety as they relate to privileges granted to a physiian. The foused professional pratie evaluation proess, however, evaluates the privilege-speifi ompetene of a physiian. Foused professional pratie evaluation is a time-limited period during whih the organization evaluates and determines the pratitioner s professional performane, usually ourring in a situation in whih there is no doumented evidene of ompetently performing the requested privilege, but also may be applied when a question arises regarding a urrently privileged pratitioner s ability to provide safe, high-quality patient are. Although the ongoing professional pratie evaluation and the foused professional pratie evaluation are tools to help identify ompeteny and possible impairment, the tools would not neessarily reognize the slow deline of a late-areer physiian. Medial and speialty organizations have released poliy statements addressing aging and impaired physiians. The Amerian Medial Assoiation Counil on Medial Eduation states: Physiians should be allowed to remain in pratie as long as patient safety is not endangered and that, if needed, remediation should be a supportive, ongoing and proative proess. Selfregulation is an important aspet of medial professionalism, and helping olleagues reognize their delining skills is an important part of self-regulation. Therefore, physiians must develop guidelines/standards for monitoring and assessing both their own and their olleagues ompeteny (1). The Amerian College of Surgeons also has made a statement on this issue reommending that starting at 65 years to 70 years, surgeons voluntarily undergo onfidential health assessments (10). Considerations Quality of Care The goal of physiians and health are institutions is to providesafeandompetentaretotheirpatients.tothis end, all linially ative physiians should maintain urrent redentials and privileges. Therefore, when onsidering the performane of a physiian, the quality of are provided and safety of the patient are of the utmost importane. Any onern of olleagues, nursing staff, or administrators should be addressed through the appropriate pathway. Competeny Assessment Development of a useful ompeteny assessment to monitor performane is imperative to evaluate physiians at any age (11). Although ompeteny assessment is frequently disussed in the literature, there has been no disussion of best methods (12). Limitations of assessment methods inlude lak of rigor of peer-review groups, reliane on self-identified problems, and the diffiulty of approahing and reporting senior peers (13, 14). Assessments ould inlude any of the following: Evaluation of mental and physial health (inluding vision, hearing, and dexterity). Areas in whih deterioration ould our over time inlude visual auity, hearing, and ognitive ability. Review of demonstrated performane of linial are Evaluation of surgial and linial expertise. Sample guidelines for ompeteny-based evaluation have been developed by California Publi Protetion and Physiian Health, In., as well as the Assoiation of Amerian Medial Colleges. Partiipation in ontinuing medial eduation that results in doumented learning and behavioral hange VOL. 131, NO. 6, JUNE 2018 Committee Opinion Late-Career Ob-Gyn e201

3 Ongoing Professional Pratie Evaluation and Foused Professional Pratie Evaluation Maintenane of ertifiation, if required External assessment and remedial eduation programs Periodi self-sreening of ognition and mental and physial wellness using validated tools Adaptations Workplae adaptations should be adopted to help obstetriian gyneologists transition and age well in their pratie and throughout their areers. Physiians who are identified as aging well by their peers have adopted ertain hanges to maintain their pratie (15 17). These inlude the following: Spending more time with patients Avoiding isolation in areas of unfamiliar pratie Retiring from intense or new proedural ativities Using memory strategies Minimizing night shifts or maintaining onsistent hours Partiipating in fewer onseutive shifts Exhange of linial duties for teahing and administration Retirement Planning Planning for retirement should start early in one s medial areer. Physiians have a unique ombination of assets and liabilities. With an intense shedule, a lak of diversified ativities, and more attention on presentday duties, there may be a lak of long-term planning for retirement. Emphasizing not just on the finanial aspets of retirement planning, but also the hanges in habits, ativities, and fous that ours with retirement is an important step in assisting the aging physiian in the transition out of ative linial pratie and maintaining a rewarding ontribution in the workplae. Retirement Poliies A poliy of mandatory retirement is inonsistent with supporting workfore partiipation among aging people. Mandatory retirement does not fit well with the urrent understanding of ognitive aging, whih is highly variable in onset and severity (18). Indeed, it would lead to a lost opportunity for junior pratitioners to benefit from the linial experiene and knowledge of longtime health are providers. Additionally, workfore issues in obstetris and gyneology, and in mediine as a whole, make mandatory retirement untenable. Mandating retirement would eliminate some of our most learned and experiened health are providers, many of whom are still providing high-quality are, from the are team at a time when our overall population is aging and requires more are. It is likely, however, that there is a ompetenybased eiling that may be related to age and may vary among different medial speialties, as well as among individuals. Arguments for a set retirement age inlude the loss of insight, whih often aompanies ognitive deline and the relutane of physiians to relinquish their medial identity (19). Hospitals may wish to onsider assessing the physial fitness of all physiians, regardless of age, on a regular basis to ensure they are physially and mentally apable of performing their duties. Muh of this deision making in how to address aging physiians has been and will be left to the redentials and medial exeutive ommittees of individual institutions, hospitals, and health are systems and should be refleted in the institutional governing bylaws and douments. To avoid the potential for legal hallenges, hospitals should address the provisions of the Age Disrimination in Employment At, making sure that assessments are equitably applied to all physiians, regardless of age. Transitional Phase Enouraging transitional phase ativities may maximize the ontributions of the aging physiian. Retention strategies an support areas of ognitive or tehnial deline and apitalize on the aging dotor s strengths. These an inlude the following: Transition from high-auity are to routine ambulatory are Transition away from major gyneologi and obstetri surgial proedures Partiipation in medial eduation at any level and ross-disiplinary teahing Serving as a mentor or preeptor Partiipation in researh Transition to leadership and administrative work Performing volunteer work Assisting in mediolegal work Conlusions Aording to the Amerian Medial Assoiation, the nation s population of physiians is aging, with 23% older than 65 years. Researh shows that as physiians age there is an inrease in ognitive deline and with that a derease in quality of are. However, there is no universal sreening proess in plae for the aging physiian. The Amerian College of Obstetriians and Gyneologists reommends that when evaluating an aging physiian, fous be plaed on the physiian s quality of are provided to patients. Although it is imperative to develop useful ompeteny assessments to monitor performane, a poliy of mandatory retirement based solely on age goes against supporting workfore partiipation among aging people and ould deprive patients of health and are and waste an opportunity to pass years of experiene e202 Committee Opinion Late-Career Ob-Gyn OBSTETRICS & GYNECOLOGY

4 on to younger physiians. Methods should be developed for physiians to age well in pratie. This ould inlude limiting all shifts, avoiding isolation in new settings, and retiring from intense or new proedural work. With this in mind, methods of transitioning an older physiian into different roles that are aeptable to the physiian should be developed while ensuring and maintaining exellent quality of are for patients. For More Information The Amerian College of Obstetriians and Gyneologists has identified additional resoures on topis related to this doument that may be helpful for ob-gyns, other health are providers, and patients. You may view these resoures at These resoures are for information only and are not meant to be omprehensive. Referral to these resoures does not imply the Amerian College of Obstetriians and Gyneologists endorsement of the organization, the organization s website, or the ontent of the resoure. The resoures may hange without notie. Referenes 1. Amerian Medial Assoiation. Report 5 of the ounil on medial eduation (a-15): ompeteny and the aging physiian. Chiago, IL: AMA; Park DC, Polk TA, Mikels JA, Taylor SF, Marshuetz C. Cerebral aging: integration of brain and behavioral models of ognitive funtion. Dialogues Clin Neurosi 2001;3: Centers for Disease Control and Prevention. The state of aging and health in Ameria Atlanta (GA): CDC; Singh-Manoux A, Kivimaki M, Glymour MM, Elbaz A, Berr C, Ebmeier KP, et al. Timing of onset of ognitive deline: results from Whitehall II prospetive ohort study. BMJ 2012;344:d Bieliauskas LA. General ognitive hanges with aging. In: Leon-Carrion J, Giannini M, editors. Behavioral neurology in the elderly. Boa Raton (FL): CRC Press; 2001: Pitkanen M, Hurn J, Kopelman MD. Dotors health and fitness to pratise: performane problems in dotors and ognitive impairments. Oup Med (Lond) 2008;58: Choudhry NK, Flether RH, Soumerai SB. Systemati review: the relationship between linial experiene and quality of health are. Ann Intern Med 2005;142: Blasier RB. The problem of the aging surgeon: when surgeon age beomes a surgial risk fator. Clin Orthop Relat Res 2009;467: Durning SJ, Artino AR, Holmboe E, Bekman TJ, van der Vleuten C, Shuwirth L. Aging and ognitive performane: hallenges and impliations for physiians pratiing in the 21st entury. J Contin Edu Health Prof 2010;30: Statement on the aging surgeon. Amerian College of Surgeons Board of Governors Physiian Competeny and Health Workgroup. Bull Am Coll Surg 2016;101: Moutier CY, Bazzo DEJ, Norross WA. Approahing the issue of the aging physiian population: data from the oalition for physiian enhanement onferene pratiing mediine longer: the impat of aging on physiian linial performane and quality of are, inluding survey opinions on the need for age-based physiian ompeteny sreening. J Med Regul 2013;99: Finuane PM, Bourgeois-Law GA, Ineson SL, Kaigas TM. A omparison of performane assessment programs for medial pratitioners in Canada, Australia, New Zealand, and the United Kingdom. International Performane Assessment Coalition. Aad Med 2003;78: Skowronski GA, Peisah C. The greying intensivist: ageing and medial pratie everyone s problem. Med J Aust 2012;196: Peisah C, Wijeratne C, Waxman B, Vonau M. Adaptive ageing surgeons. ANZ J Surg 2014;84: Peisah C, Gautam M, Goldstein MZ. Medial masters: a pilot study of adaptive ageing in physiians. Australas J Ageing 2009;28: Eva KW. The aging physiian: hanges in ognitive proessing and their impat on medial pratie. Aad Med 2002;77(10 suppl):s Amerian College of Emergeny Physiians. Clinial and pratie management: onsiderations for emergeny physiians in pre-retirement years. Irving (TX): ACEP; Christensen H. What ognitive hanges an be expeted with normal ageing? Aust N Z J Psyhiatry 2001;35: Peisah C, Wilhelm K. Physiian don t heal thyself: a desriptive study of impaired older dotors. Int Psyhogeriatr 2007;19: Copyright June 2018 by the Amerian College of Obstetriians and Gyneologists. All rights reserved. No part of this publiation may be reprodued, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, eletroni, mehanial, photoopying, reording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photoopies should be direted to Copyright Clearane Center, 222 Rosewood Drive, Danvers, MA 01923, (978) Amerian College of Obstetriians and Gyneologists th Street, SW, PO Box 96920, Washington, DC The late-areer obstetriian gyneologist. ACOG Committee Opinion No Amerian College of Obstetriians and Gyneologists. Obstet Gyneol 2018;131:e VOL. 131, NO. 6, JUNE 2018 Committee Opinion Late-Career Ob-Gyn e203

5 This information is designed as an eduational resoure to aid liniians in providing obstetri and gyneologi are, and use of this information is voluntary. This information should not be onsidered as inlusive of all proper treatments or methods of are or as a statement of the standard of are. It is not intended to substitute for the independent professional judgment of the treating liniian. Variations in pratie may be warranted when, in the reasonable judgment of the treating liniian, suh ourse of ation is indiated by the ondition of the patient, limitations of available resoures, or advanes in knowledge or tehnology. The Amerian College of Obstetriians and Gyneologists reviews its publiations regularly; however, its publiations may not reflet the most reent evidene. Any updates to this doument an be found on or by alling the ACOG Resoure Center. While ACOG makes every effort to present aurate and reliable information, this publiation is provided as is without any warranty of auray, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the produts or servies of any firm, organization, or person. Neither ACOG nor its offiers, diretors, members, employees, or agents will be liable for any loss, damage, or laim with respet to any liabilities, inluding diret, speial, indiret, or onsequential damages, inurred in onnetion with this publiation or reliane on the information presented. All ACOG Committee members and authors have submitted a onflit of interest dislosure statement related to this published produt. Any potential onflits have been onsidered and managed in aordane with ACOG s Conflit of Interest Dislosure Poliy. The ACOG poliies an be found on aog. org. For produts jointly developed with other organizations, onflit of interest dislosures by representatives of the other organizations are addressed by those organizations. The Amerian College of Obstetriians and Gyneologists has neither soliited nor aepted any ommerial involvement in the development of the ontent of this published produt. e204 Committee Opinion Late-Career Ob-Gyn OBSTETRICS & GYNECOLOGY